The Main Components of Body Image from the Perspectives of Iranian Adolescents: A Qualitative Study


 Background: This study investigates main components of body image from the perspectives of Iranian boys and girls. Methods: A qualitative approach was used to identify the main components of body image in Iranian adolescents. A total of 13 semi-structured focus group discussions were conducted with 84 adolescents (42 girls and 42 boys), aged 15–18 years. All focus group discussions were audio recorded and transcribed verbatim, followed by a qualitative content analysis of the data.Results: The mean age and BMI of participants were 16.2±0.9 years and 24.3±8.0 kg/m2 respectively. Regarding main components of body image, three main themes emerged from the data: 1) perceived face/hair, which included three subthemes-facial features, facial shape/form and hair, 2) perceived body, which included three subthemes-body size, body shape and bone structure and 3) perceived physical functioning which included three subthemes-physical ability, physical health and voice tone. Among mentioned themes, perceived body was the concept which was most frequently addressed by both adolescent boys and girls. When adolescents were talking about their bodies, girls more frequently mentioned their faces and its components, while boys tended to talk more about their physical functioning. Conclusion: This qualitative study provide further insight into the components of body image as perceived by Iranian boys and girls. Current findings indicated that besides those features that focused on body appearance and its aesthetic aspects, physical functioning was another main component of perceived body image by participants. These findings can contribute to the design and implementation of effective interventions aiming at improving body image and its related disorders in Iranian adolescents.

. For example, ideal body size has been shown to differ across people of various ethnicities in the U.S. with larger body size being preferred more by Hispanic and Native American girls compared to their white counterparts [15]. In another cross-cultural study, although some body characteristics such as weight/shape; muscle; and upper, middle and lower body contributed similarly to body dissatisfaction in all male adolescents; Asian male adolescents found height, hair and face to contribute to their overall body dissatisfaction more compared to their Australian counterparts [16]. Although some components that contribute to body dissatisfaction may be universal; due to differences in cultural values in societies, the characteristics of an ideal body and body parts that get more attention may differ in various countries.
Though extensively studied in Western societies, there is a gap in existing evidence qualitatively examining body image in Iranian adolescents. Most of the existing evidence on body image among Iranian adolescents has mainly focused on the prevalence of body dissatisfaction and its association with other variables using a quantitative approach [18][19][20][21][22]. Therefore, to the best of our knowledge there is no evidence which explored the main components of body image from the perspective of Iranian adolescents. Given the paucity of evidence from Iran on this topic, the current study employs a qualitative approach to get better insights into the perceptions of Iranian boys and girls regarding their bodies and the main components that contribute to their body image.

Participants
This qualitative study used a grounded theory approach. Study participants were 84 adolescents (42 girls and 42 boys) aged 15-18 years, who were recruited from seven high schools in Tehran (four all-boys schools and three all-girls schools). In an effort to obtain various experiences from different socioeconomic status, participants were selected from two different geographic areas in Tehran including north and south areas, representing areas of generally higher and lower socio-economic status, respectively. In each area, one district was randomly selected. Then the lists of all high schools in the selected districts were prepared, and eight high schools (four school for each gender) were selected using simple random sampling method. In each selected high school, based on the factors that could in uence body image including appearance features, educational background, study majors and grades, number of students were selected and invited by school staff to participate in the current study. Of students who were invited, the current focus group discussions were scheduled for those who agreed to participate in the study and complete the consent forms.

Data collection
Data was collected using semi-structured focus group discussions conducted by two interviewers who had experience in conducting focus group discussions with adolescents. Prior to the initiation of the discussions, the interviewers introduced themselves and informed participants of the aim of the study.
They further explained that participants are expected to share their views and experiences regarding body image with a focus on their body characteristics. Data was collected between October 2018 and May 2019 through 13 same-gender focus group discussions with 6-8 participants in each focus group. The duration of focus group discussions ranged from 60-90 minutes. All sessions were audiotaped and transcribed verbatim by the rst author. In addition, notes were taken about nonverbal signals that participants exhibited. After each focus group discussion, participants were asked to complete a form which includes socio-demographic information and self-reported weight and height. Each discussion was initiated by this question: "What do you think is the meaning of the term body image?". After participants answered this question, a brief de nition of the term "body image" was provided by the interviewer. Then, the discussion continued with open-ended questions as provided in the interview guide which has been developed for the current study (Additional le 1). Some example of the questions are as follows: -When was the rst time you noticed and judged your body? Which body parts caught your attention?
-If you want to evaluate your body, what score would you give yourself on a scale of 0 to 20? -Why did you give yourself that score?
-In your opinion what are the characteristics of an ideal body in your age?
-If you could make a change in your appearance, what would that change be?

Data analysis
Data collection and analysis was conducted simultaneously. Data collection continued until the researchers believed saturation was reached, in which no new themes were observed. Data analysis was done manually using constant comparative analysis according to the Strauss and Corbin analysis method. Open, axial and selective coding were applied to the data. All transcripts were coded by the rst author line by line and differences in coding were resolved through discussion with the other researchers. Discussion between the research team members helped to explore various interpretations of the ndings to reach agreements regarding nal themes.
To ensure trustworthiness in the current study, participants were selected from two genders, various study majors and weight levels (underweight, normal weight, overweight/obese) as well as socio-economic statuses to enrich the exploration of the study objective. In addition, to allow for a safe space for participants to openly discuss sensitive matters, all sessions were conducted in a private room in the schools, with no school staff present. Furthermore, to provide the chance of building trust and becoming familiar with the setting and context, a prolonged engagement of researchers with participants was applied. During the sessions, the interviewers restated and summarized the participants' statements and asked them to con rm accuracy during data collection. Codes also underwent respondent validation with a random subset of the participants. Additionally, three faculty members and a research assistant were asked to conduct a second review of the analysis.

Ethics
Ethics approval was obtained from the ethics committee of the Research Institute for Endocrine Sciences (RIES) of Shahid Beheshti University of Medical Sciences in Iran. Informed consent was obtained from all participants and their parents prior to their involvement and permission to audiotape the focus groups was granted by participants. All participants were made aware that their identity and data would remain anonymous and con dential and that they could voluntarily withdraw from the study at any time without consequence.

Results
The mean age and BMI of participants were 16.2 ± 0.9 years and 24.3 ± 8.0 kg/m 2 , respectively. The majority of participants had married parents and about half of both mothers and fathers of participants had academic degrees. More than two thirds of participants' mothers were housewives and the majority of participants' fathers were employed. Residential, paternal and maternal characteristics of study participants are presented in Table 1. The body image components that emerged from the data were categorized into three main themes: 1) perceived face/hair, 2) perceived body and 3) perceived physical functioning. The rst two themes are related to body appearance, while the latter refers to how body functions. Themes, subthemes, and codes are summarized in Table 2. This theme refers to the main characteristics of adolescents' face/hair which could affect their perception of and satisfaction with their body. These facial characteristics were categorized into three main subthemes including: 1) facial features, 2) facial shape/form and 3) hair. In the current study, girls more frequently focused on their facial appearance than did boys. Regarding facial features, most participants indicated that their nose, eyes, skin and mouth were the most important components of their face.
Characteristics related to the nose and mouth were mostly referenced by girls, with a considerable number of girls commenting on the size and shape of their nose: "I see some aws in my face that I would like to change; for example, I don't like my nose, it may need cosmetic surgery when I grow older" (a 16-year old girl). All comments related to characteristics of the mouth were stated by girls, which mainly focused on teeth "If I have money, after doing vision correction surgery, I would spend the remaining on straightening my teeth" (a 16-year old girl), and lips "Beautiful lips must be plump" (a 17-year old girl). On the other hand, characteristics related to skin and eyes were addressed by both girls and boys. In terms of eyes, participants commonly referred to size: "I personally like a person who has pretty eyes, beautiful eyes like big eyes." Facial shape/form was another subtheme that was referenced frequently, such as jawline shape, cheekbone shape and natural face (i.e., not cosmetically enhanced). These characteristics were mentioned more frequently by girls than boys. Jawline shape was a characteristic that was mentioned by both girls and boys: "For example, some individuals have angles on their faces, when you look at them this part of their face (the participant referred to the angles of her chin and ears) is angled." (a 16-year old girl). Another comment made by a boy in reference to his jawline shape was: "In terms of face form, I'm not very satis ed with myself at all, I like certain things that I don't have, so I'm not satis ed. For example, an angled face." (a 17-year old boy). Cheekbone shape and natural face were two characteristics that emerged from comments made only by girls: "An attractive girl has cheekbones" (a 17-year old girl), and "In my opinion, she [an Iranian actress] is very good, she is whatever she is, she doesn't have any cosmetic surgery" (a 16-year old girl).
Another feature of the face that was pointed out by both adolescent boys and girls was hair. Adolescents mentioned characteristics related to the density and color of the hair on their head: "I have hair loss and I cannot make a series of hairstyles because of my little hair, so I lose my body points because of it" (a 16year old girl) and "Another feature of an ideal body is blond hair" (a 17-year old boy). In addition, facial hair including eyelashes, eyebrows and a beard were other characteristics that in uenced adolescents' perception of body image: "Some individuals have very long lashes, some have very good eyebrows" (a 17-year old boy), and "He has a beautiful face, his beard is nice" (a 16-year old boy).

Theme 2: Perceived body
The second main theme that emerged from the data is perceived body which mainly focused on its shape and size. This concept was further categorized into three subthemes: 1) body size, 2) body shape and 3) bone structure. Body size, more speci cally body weight and height, was the most frequently discussed subtheme by both boys and girls. In terms of weight, most adolescent boys and girls were dissatis ed with their perceived excess weight: Another subtheme of perceived body was body shape which mainly relates to the waist and abdomen, body muscles and feminine curves. Waist and abdomen were referred to by both boys and girls with a higher frequency in girls: "I am not very satis ed with myself for many years, for example, I sit down and say how big my abdomen is, it is really big! I mean for example when I wear tight clothes it seems that it is bigger than other parts" (a 15-year old girl)." The ideal body should have no abdomen, no ank!" (a 16year old boy). Adolescents, primarily boys, referred to a muscular body as an ideal body: "The body has to be in shape, because it's not just about being lean. Sometimes thinness makes the body ugly, a thin body with muscles has a good shape, and an individual must go to gym and have toned muscle." (a 15-year old girl). "Actually, a good body should have a six-pack" (an 18-year old boy). Feminine curves was exclusively mentioned by girls, in which bust and hips were areas that were emphasized: "It is obvious, an attractive body should be like an hourglass!" (a 17-year old girl).
With regards to the next subtheme of perceived body entitled as bone structure, comments made were related to different parts of skeletal structure. Some comments referring to neck length, clavicle form and knee angle were made only by girls: "An ideal body should have a long neck" (a 16-year old girl), and "An attractive body is a body with a distinct clavicle bone" (a 17-year old girl) and "The knee angle and its shape is important. For example, it is important whether it is x-shaped, bowed or normal." (a 17-year old girl). Shoulder width was a bone structure characteristic that was exclusively pointed out by boys "I tried to create what I had in my mind, I was interested in body building and athletic body style and I tried to work out and broad shoulders was one of the things that mattered to me". (a 17-year old boy). Finally, posture was another feature that was brought up by both adolescent girls and boys: "It's also really bad, like trying to wear something and you have a hump on your back! It's so ugly!" (a 15-year old girl) and "One point was my hunchback; for example, relatives said my mother, why does your son have a hunchback? And I was humiliated constantly" (a 16-year old boy).

Theme 3: Perceived physical functioning
In addition to face and body appearance, according to perspectives of current study participants, how the body functions in uence adolescents' perception regarding their bodies. The physical functioning theme had three main subthemes including 1) physical ability, 2) physical health and 3) voice. Physical ability referred to both physical readiness "Whenever we had a race with other kids, I was out of breath because I'm overweight, it gave me a bit of trouble, I was always the last person" (a 16-year old boy); "In my opinion, many of the effects of body shape are on body abilities rather than its appearance and beauty. I have understood this in my everyday life many times; for example, I went to the mountains with my family on holiday. Compared to my cousin who is very obese, I climbed up the mountain very quickly. Also my aunt who doesn't exercise and get t barely climbed up the mountain and she had a leg ache." (a 16-year old girl) and ability for doing routine activities: "Obesity is not really good in some situations, for example, if an earthquake happen, I am slower than thin people, I may fall under the rubble" (a 17-year old boy). In terms of physical ability, adolescent boys focused more on physical readiness compared to adolescent girls.
Another feature of physical functioning referred to adolescents' assessment of their physical health which encompassed two main components: lack of disability and illness, and abnormal symptoms. From the perspective of adolescents, physical functioning was tied to lack of illness "I don't give a full score to my body, because of the problems I have, like headache or the diseases I have, including sinusitis" (a 16year old girl) and disability "I give myself a full score because I'm healthy, there are some people who don't even have hands" (a 15-year old boy). In addition, abnormal symptoms was another feature of physical functioning which in uenced adolescents' perceived body image: "I lose two points because I don't have regular menstruation, for example, I menstruate every three months" (a 15-year old girl) which in some cases could also have negative effects on their social interactions "I also lose 5 points for having sweaty palms, because for example when I get in touch with someone, I feel sweaty and it hurts a lot." (a 17-year old boy).
Voice was a component of physical functioning that was mainly mentioned by boys: "I am dissatis ed with my voice, for example, two years ago, my classmates made fun of my voice and said I sound like an addict". (a 16-year old boy), and "One of my friends has a six-pack and his voice is attractive, that's why everyone pays attention to him. For example, once we went to the park, everyone gathered around him." (a 16-year old boy).

Discussion
The current study aimed to explore components of body image from the perspective of Iranian adolescent boys and girls. From this study, three main components of body image emerged from the data: perceived face/hair, perceived body and perceived physical functioning. Of these body image components, participants most frequently referred to perceived body (body shape and size) compared to the two other components. In addition, there was a gender difference in the ndings with comments related to appearance (perceived face/hair and perceived body) being more prominent in girls' statements, while comments related to physical functioning were more dominant in boys' statements. In addition, comments made by several girls related to short height, a natural face, neck length, clavicle form and knee angle as well as comments made by boys related to voice tone were among the novel ndings of the current study that are less addressed in the previous related research.
Based on the ndings of the current study, perceived body was the most important component of body image and body features related to body size, shape and bone structure were frequently addressed in adolescents' quotes. Of characteristics of perceived body, those features that re ected body size including body weight and height were prominent in adolescents' statements implying that body size is a focal point in body perception of Iranian adolescents. In the current study, most of participants believed that a slim body, or a normal sized body, could be an ideal body. Furthermore, the majority of girls and all boy wished to be tall. These nding are consistent with ndings from other parts of the world that have suggested a preference for thinness and tallness [23][24][25][26][27][28]. The preference for slim body by Iranian adolescents in the current study, is in accordance with thin idealization in Western culture. However, surprisingly, a minority of adolescent girls in the current study were dissatis ed with their tallness and preferred a shorter height. Except for body size, participants pointed out to body features that re ect its shape. In this regard, a considerable number of girls referred to a curvaceous body as an ideal female body, while the majority of boys and few girls perceived a muscular body to be an ideal body. This nding is in agreement with ndings of previous studies in which a curvaceous female body and a muscular male body were perceived as ideal body shapes by girls and boys respectively [29,30]. Other than body size and shape, to a lesser extent, adolescents pointed out other features which were associated with their bone structure. Of these features, neck length, clavicle form and knee angle were mentioned by girls and shoulder width was mentioned by boys. Posture was the only bone structure feature that was associated with body perception for both adolescent boys and girls.
Participants of this study believed that characteristics of their face and hair could in uence their perception and satisfaction about their bodies as well. The focus on facial features was more prominent in girls' statements compared to that of boys, implying that facial appearance is a more salient bodyrelated concern in girls. In line with this nding, previous studies also indicated a gender difference pattern regarding body features that are emphasized by adolescent boys and girls [23]. Furthermore, current study found that some features such as big eyes, colored eyes, straight white teeth, plump lips, a small and upturned nose, smooth and bright skin, thick and long hair, and long eyelashes were perceived as desirable traits by participants, which is similar to previous studies [29,31]. While most of the current study participants had dark-colored eyes and hair, having blue/green eyes, blond hair and an upturned nose were desired by them, which are more commonly idealized body features in Western societies [32]. Among facial features, the nose was most talked about among girls. This is not surprising, because based on previous reports, rhinoplasty is among the most commonly performed cosmetic surgeries in Iran and it is highly demanded by Iranians [33]. The high demand for rhinoplasty among Iranian girls may not only improve their perceived facial aesthetics, but may also be considered as a way to achieve a successful marriage and a nancially powerful appearance [34]. To a lesser degree, characteristics related to facial shape, in uenced participants' perceptions regarding their bodies. These features included a sharper jawline according to both girls and boys, and high cheekbones and a natural face mentioned only by girls. Regarding the latter, a number of girls were opposed to cosmetic surgeries and believed that a natural face without cosmetic enhancement is more attractive than faces that have undergone cosmetic surgeries.
Irrespective of mentioned themes that mainly pointed out body appearance, a considerable number of participants alluded to physical functioning, speci cally their physical ability, physical health and voice, as important aspects of their body image. In agreement with this nding, previous studies found that body image is not limited to body appearance and its aesthetic aspects, it is also impacted by perceived physical abilities, functions and health [14,35,36]. For example, Malaysian adolescents indicated their main reason for being concerned about their body shape is "to be healthy" (71%) rather than "to look good" (11.6%) [14]. Interestingly, in the study conducted by Abbot & Barber, the investigators pointed out that while functionality is less so considered in body image measurements, when it is integrated into related assessments in adolescents, its value transcends body appearance [36]. A more unique nding in the current study is the importance placed on voice by adolescent boys. Although this feature is mentioned less in previous studies, another study also found that adolescents referred to voice as a source of body dissatisfaction [27].
This qualitative study is among the rst to explore body image components perceived by Iranian boys and girls. A strength of this study is that male and female participants were selected from different socioeconomic and weight status groups with the aim of maximizing variation in sampling. Considering selecting participants from an urban community, current ndings do not re ect perspective of suburban and rural adolescents and further research in these settings is needed to broaden our understanding regarding main components of body image from the perspective of Iranian adolescents.

Conclusion
Findings from the current qualitative study provide further insight into the components of body image as perceived by Iranian boys and girls which re ect perspectives of adolescents living in Easter-